Recommended Evacuation Routes for DCS or AGE at Altitude?

[TheAvatar]

So here is a hypothetical that I've been wondering about for a while:

Hypothetical 1:
Diver takes a hit at 9000ft ASL.

Nearest clinic 1: 10 minutes to a Level IV trauma "hospital" (read 24 beds total most of them ED) with no extended care at 9050ft often with a small unpressurized helicopter often based there.

Alternate clinic 2: 50 minutes to even smaller "hospital" at 7350ft (downhill all the way) with airport within 5 minutes capable of pressurized fixed wing medevac (nearest airport to incident).

Nearest chamber: Major hospital 5300ft 1.5+hr away by ambulance from Clinic 1 (2+hr from Clinic 2) over mountains with peak elevation ~11,000ft (~30 minutes from either clinic via unpressurized helicopter peaking at at least 13,000ft).

What is the best method to transport the patient (weather and asset permitting)?

Clinic 1-Ambulance-Hospital?

Clinic 1-Helicopter-Hospital?

Clinic 2-Fixed Wing-Helicopter/Ambulance-Hospital?

Something else?

Second hypothetical:
Diver takes a hit at 8300ft ASL.

Nearest clinic 3: 20 minutes to a small medical center 8000ft with airport within 5 minutes capable of pressurized fixed wing medevac (nearest airport to incident).

Alternate clinic 2 (from above): 50 minutes to similar "hospital" at 7350ft with airport within 5 minutes capable of pressurized fixed wing medevac.

Nearest chamber: Major hospital 5300ft 1.5+hr away by ambulance from Clinic 3 (2+hr from Clinic 2) over mountains with peak elevations 11,315ft (~30 minutes from either clinic via unpressurized helicopter peaking at at least 12,000ft).

Fixed wing aircraft are not based at sending airports. Additional helicoptors near receiving hospital. Clinics 1,2,3 personell see HAPE, HACE, AMS not DCS or AGE.

What transport method in that case?

I know there are a lot of variables here but I'd be interested to hear some thoughts/answers.

 

[Doc Intrepid]

Alternate hypothetical: Ensure you plan and execute dives above 8000' so conservatively that no one takes a hit in the first place.

There are no good answers. Both altitude or prolonged elapsed time will exacerbate the damage. Get your diver (on O2) to the chamber as quickly as possible (helicopter, weather permitting) and deal with it there.

 

[TheAvatar]

Alternate hypothetical: Ensure you plan and execute dives above 8000' so conservatively that no one takes a hit in the first place.

This is a hypothetical with me as a responder. I'm wondering what the transport order would likely be. I'd either be responding as an EMT with Dive Rescue or with the ambulance service.

Our dive team takes exceptional caution and we dive weekly on the 10,000ft table with no dive accidents since the team was formed over 20 years ago.

Apart from the small PSD team, divers are rare up here and I've never heard of anyone getting DCI in this area, but there are some local and tourists who do dive at altitude and I had just been thinking about what would be done with our peculiar location situation.

There are no good answers. Both altitude or prolonged elapsed time will exacerbate the damage. Get your diver (on O2) to the chamber as quickly as possible (helicopter, weather permitting) and deal with it there.

So you think unpressurized helicoptor is the best because it is the fastest? What about having the helicopter respond to the scene rather than transporting to a clinic and flying from there?

 

[Wildcard]

I guess Id have to go with number 2. A trauma center won't make a diff if they have no chamber and I guessing they don't. With the advances in hyperbaric medicine that are happining right now, every hospital may have one in the next few years.
Just a thought on helicopters. Just becouse they fly dosen't make them faster. Ive been on the ground and in the air for many years and ground is often a better choice. I find people just like to play with the helos so they get called a lot. It's flat out hard to do good care while having your fillings viberated out.....On scene, determin a helo is needed. Call out, 10 minutes to launch, 15 minute flight, 15 on the ground while the patient is reassesed, 15 minute flight back, 10 minutes to offload and get into the ER. Not so fast is it?

 

[TheAvatar]

Just a thought on helicopters. Just becouse they fly dosen't make them faster. Ive been on the ground and in the air for many years and ground is often a better choice. I find people just like to play with the helos so they get called a lot. It's flat out hard to do good care while having your fillings viberated out.....On scene, determin a helo is needed. Call out, 10 minutes to launch, 15 minute flight, 15 on the ground while the patient is reassesed, 15 minute flight back, 10 minutes to offload and get into the ER. Not so fast is it?

You make very good points. It can be nice around here with the helo in county and you can put it on airborne standby the moment you are toned out to a call where you think you'll need it and underthose circumstances it can definately be a lot faster than a 60 mile ground transport through weekend ski traffic. Of course thats all optimal. Life isn't.

 

[Wildcard]

Then you need to ask "faster to what?" High flow ozzz and pain control are about all the hospitals can do too.

 

[Dr Deco]

Hello readers:

I was taught that it is best to proceed to the nearest chamber – multiplace if at all possible. :doctor:

Secondary sites without proper recompression will lose valuable time in the long run, experience has shown. Oxygen breathing should always be performed at all times during the transit.

Dr Deco :doctor:

 

[Wildcard]

After reading again, I see that there is a deco chamber available. That would be the obvious choice with transport by ground. I guess I should read more carefully.

 

[ArcticDiver]

If you are in charge then:
-What do your Standing Orders say? If silent, then discuss with your Medical Director so the subject can be included in them.
-Is it really DCS? The most likely thing is that although you suspect DCS it really isn't. You are ill equipped in the field to make a definitive diagnosis.
-Remember the ABCs. Make sure that is always taken care of. In that regard getting the patient to the nearest place for critical care if the patient crashes is most important.
-Taking the patient directly to the Chamber unless an online consult arrives at that decision is almost always a bad idea. What if patient needs critical care due to some other complaint? Is chamber in service? Is staff available? So, use the usual EMS chain for best patient assessment, diagnosis and care.
-Remember the reason you are in charge is because you are trained to look at the big picture, not jump to conclusions. Also, remember the reason you do assessments and not diagnosis is because, political considerations aside, you don't have the tools in the field to do a diagnosis.

Use the EMS system. It gives the patient the best chance of accurate diagnosis and effective treatment. You short cut the system at risk of the patient's life and your career.

 

[Dr Deco]

Artic Diver is correct insuggesting the telephone consult. That was not part of the question but is nevertheless correct.

My comment was direct solely to recompression. Again, I was taught that multiplace chambers with the ability to go deeper than 60 fsw were the perfered treatment locals. I suspect that these "deep chambers" have taken many referral cases of unsuccesful treatments in monoplace chambers.